Prescription Form

• Private pay or Insurance? Call us for a free consultation: 813-631-9700
• Click here to Download Patient Prescription Form. Print out and bring to your physician, ask him/her to sign for your Therapy asap.
• Fill out the physician's info below and we'll request for you.

Your Name:	First   Last (*)
Email:	(*)
Date of Birth:
- Select Phone - Cell Phone Work Phone Home Phone Fax
- Select Phone - Cell Phone Work Phone Home Phone Fax
- Select Phone - Cell Phone Work Phone Home Phone Fax
Insurance info:
Private Pay?	Yes     No
Name of Insurance company:
Policy number:
Group number:
Provider phone number:
HMO plan?	Yes    No
Have a Secondary insurance info?	Yes    No
Secondary Name of Insurance company:
Secondary Policy number:
Secondary Group number:
Secondary Provider phone number:
Physician Name:	First   Last
Practice Name:
- Select Phone - Cell Phone Work Phone Home Phone Fax
- Select Phone - Cell Phone Work Phone Home Phone Fax
- Select Phone - Cell Phone Work Phone Home Phone Fax
- Select Phone - Cell Phone Work Phone Home Phone Fax
Address 1:
Address 2:
Address 3:
What problems are you seeking treatment for?
Any particular staff there whom we should ask for?
Any special message from you to the physician's office?
Any special message to us?
To prevent spammer from abusing our website, please answer this simple question: Who is the first president of the United States? (*)

Decide, take charge of your better health today!